Request a BurkePsych Secure Mail Account

You indicated on the previous page that you are one of Dr. Burke's current clients. Any of Dr. Burke's current clients may request a secure email. To protect your privacy, I need to first confirm that you are who you say that you are. This prevents someone from creating an account in your name without your knowledge. If you are uncomfortable including information in this form, simply complete what you wish and I will contact you to confirm your request.

Please complete the form below to set up an account.

Your Name:   Date of Birth:

E-Mail:   Confirm your E-Mail:

Preferred Phone:   Last 4-digits of SSN:

Type of service I am providing to you now: online counseling individual counseling/therapy couples' counseling testing/evaluation other

Date of last session:

If using insurance, your policy ID:


Tell me something only I would know about you:

Security Question:
           (not selected) What is the name of your pet? In what county were you born? What is a secret word of your choosing? What is the first name of your paternal grandfather? What is your mother's maiden name?
  Answer to security question:

(Please click only once - encryption may take a few moments)

For best encryption, be sure you have the Java Runtime Environment installed on your computer.

If you reached this page in error and are not a current client, please click here.